Intensive systolic blood pressure control and incident chronic kidney disease in people with and without diabetes mellitus

secondary analyses of two randomised controlled trials

Srinivasan Beddhu, Tom Greene, Robert Boucher, William Cushman, Guo Wei, Gregory Stoddard, Joachim H. Ix, Michel Chonchol, Holly Kramer, Alfred K. Cheung, Paul L. Kimmel, Paul K. Whelton, Glenn M. Chertow

Research output: Contribution to journalArticle

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Abstract

Background: Guidelines, including the 2017 American College of Cardiology and American Heart Association blood pressure guideline, recommend tighter control of systolic blood pressure in people with type 2 diabetes. However, it is unclear whether intensive lowering of systolic blood pressure increases the incidence of chronic kidney disease in this population. We aimed to compare the effects of intensive systolic blood pressure control on incident chronic kidney disease in people with and without type 2 diabetes. Methods: The Systolic Blood Pressure Intervention Trial (SPRINT) tested the effects of a systolic blood pressure goal of less than 120 mm Hg (intensive intervention) versus a goal of less than 140 mm Hg (standard intervention) in people without diabetes. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) blood pressure trial tested a similar systolic blood pressure intervention in people with type 2 diabetes. Our study is a secondary analysis of limited access datasets from SPRINT and the ACCORD trial obtained from the National Institutes of Health. In participants without chronic kidney disease at baseline (n=4311 in the ACCORD trial; n=6715 in SPRINT), we related systolic blood pressure interventions (intensive vs standard) to incident chronic kidney disease (defined as >30% decrease in estimated glomerular filtration rate [eGFR] to <60 mL/min per 1·73 m2). These trials are registered with ClinicalTrials.gov, numbers NCT01206062 (SPRINT) and NCT00000620 (ACCORD trial). Findings: The average difference in systolic blood pressure between intensive and standard interventions was 13·9 mm Hg (95% CI 13·4–14·4) in the ACCORD trial and 15·2 mm Hg (14·8–15·6) in SPRINT. At 3 years, the cumulative incidence of chronic kidney disease in the ACCORD trial was 10·0% (95% CI 8·8–11·4) with the intensive intervention and 4·1% (3·3–5·1) with the standard intervention (absolute risk difference 5·9%, 95% CI 4·3–7·5). Corresponding values in SPRINT were 3·5% (95% CI 2·9–4·2) and 1·0% (0·7–1·4; absolute risk difference 2·5%, 95% CI 1·8–3·2). The absolute risk difference was significantly higher in the ACCORD trial than in SPRINT (p=0·0001 for interaction). Interpretation: Intensive lowering of systolic blood pressure increased the risk of incident chronic kidney disease in people with and without type 2 diabetes. However, the absolute risk of incident chronic kidney disease was higher in people with type 2 diabetes. Our findings suggest the need for vigilance in monitoring kidney function during intensive antihypertensive drug treatment, particularly in adults with diabetes. Long-term studies are needed to understand the clinical implications of antihypertensive treatment-related reductions in eGFR. Funding: National Institutes of Health.

Original languageEnglish (US)
Pages (from-to)555-563
Number of pages9
JournalThe Lancet Diabetes and Endocrinology
Volume6
Issue number7
DOIs
StatePublished - Jul 1 2018

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Chronic Renal Insufficiency
Diabetes Mellitus
Randomized Controlled Trials
Blood Pressure
Type 2 Diabetes Mellitus
National Institutes of Health (U.S.)
Glomerular Filtration Rate
Antihypertensive Agents

All Science Journal Classification (ASJC) codes

  • Internal Medicine
  • Endocrinology, Diabetes and Metabolism
  • Endocrinology

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Intensive systolic blood pressure control and incident chronic kidney disease in people with and without diabetes mellitus : secondary analyses of two randomised controlled trials. / Beddhu, Srinivasan; Greene, Tom; Boucher, Robert; Cushman, William; Wei, Guo; Stoddard, Gregory; Ix, Joachim H.; Chonchol, Michel; Kramer, Holly; Cheung, Alfred K.; Kimmel, Paul L.; Whelton, Paul K.; Chertow, Glenn M.

In: The Lancet Diabetes and Endocrinology, Vol. 6, No. 7, 01.07.2018, p. 555-563.

Research output: Contribution to journalArticle

Beddhu, Srinivasan ; Greene, Tom ; Boucher, Robert ; Cushman, William ; Wei, Guo ; Stoddard, Gregory ; Ix, Joachim H. ; Chonchol, Michel ; Kramer, Holly ; Cheung, Alfred K. ; Kimmel, Paul L. ; Whelton, Paul K. ; Chertow, Glenn M. / Intensive systolic blood pressure control and incident chronic kidney disease in people with and without diabetes mellitus : secondary analyses of two randomised controlled trials. In: The Lancet Diabetes and Endocrinology. 2018 ; Vol. 6, No. 7. pp. 555-563.
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abstract = "Background: Guidelines, including the 2017 American College of Cardiology and American Heart Association blood pressure guideline, recommend tighter control of systolic blood pressure in people with type 2 diabetes. However, it is unclear whether intensive lowering of systolic blood pressure increases the incidence of chronic kidney disease in this population. We aimed to compare the effects of intensive systolic blood pressure control on incident chronic kidney disease in people with and without type 2 diabetes. Methods: The Systolic Blood Pressure Intervention Trial (SPRINT) tested the effects of a systolic blood pressure goal of less than 120 mm Hg (intensive intervention) versus a goal of less than 140 mm Hg (standard intervention) in people without diabetes. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) blood pressure trial tested a similar systolic blood pressure intervention in people with type 2 diabetes. Our study is a secondary analysis of limited access datasets from SPRINT and the ACCORD trial obtained from the National Institutes of Health. In participants without chronic kidney disease at baseline (n=4311 in the ACCORD trial; n=6715 in SPRINT), we related systolic blood pressure interventions (intensive vs standard) to incident chronic kidney disease (defined as >30{\%} decrease in estimated glomerular filtration rate [eGFR] to <60 mL/min per 1·73 m2). These trials are registered with ClinicalTrials.gov, numbers NCT01206062 (SPRINT) and NCT00000620 (ACCORD trial). Findings: The average difference in systolic blood pressure between intensive and standard interventions was 13·9 mm Hg (95{\%} CI 13·4–14·4) in the ACCORD trial and 15·2 mm Hg (14·8–15·6) in SPRINT. At 3 years, the cumulative incidence of chronic kidney disease in the ACCORD trial was 10·0{\%} (95{\%} CI 8·8–11·4) with the intensive intervention and 4·1{\%} (3·3–5·1) with the standard intervention (absolute risk difference 5·9{\%}, 95{\%} CI 4·3–7·5). Corresponding values in SPRINT were 3·5{\%} (95{\%} CI 2·9–4·2) and 1·0{\%} (0·7–1·4; absolute risk difference 2·5{\%}, 95{\%} CI 1·8–3·2). The absolute risk difference was significantly higher in the ACCORD trial than in SPRINT (p=0·0001 for interaction). Interpretation: Intensive lowering of systolic blood pressure increased the risk of incident chronic kidney disease in people with and without type 2 diabetes. However, the absolute risk of incident chronic kidney disease was higher in people with type 2 diabetes. Our findings suggest the need for vigilance in monitoring kidney function during intensive antihypertensive drug treatment, particularly in adults with diabetes. Long-term studies are needed to understand the clinical implications of antihypertensive treatment-related reductions in eGFR. Funding: National Institutes of Health.",
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T1 - Intensive systolic blood pressure control and incident chronic kidney disease in people with and without diabetes mellitus

T2 - secondary analyses of two randomised controlled trials

AU - Beddhu, Srinivasan

AU - Greene, Tom

AU - Boucher, Robert

AU - Cushman, William

AU - Wei, Guo

AU - Stoddard, Gregory

AU - Ix, Joachim H.

AU - Chonchol, Michel

AU - Kramer, Holly

AU - Cheung, Alfred K.

AU - Kimmel, Paul L.

AU - Whelton, Paul K.

AU - Chertow, Glenn M.

PY - 2018/7/1

Y1 - 2018/7/1

N2 - Background: Guidelines, including the 2017 American College of Cardiology and American Heart Association blood pressure guideline, recommend tighter control of systolic blood pressure in people with type 2 diabetes. However, it is unclear whether intensive lowering of systolic blood pressure increases the incidence of chronic kidney disease in this population. We aimed to compare the effects of intensive systolic blood pressure control on incident chronic kidney disease in people with and without type 2 diabetes. Methods: The Systolic Blood Pressure Intervention Trial (SPRINT) tested the effects of a systolic blood pressure goal of less than 120 mm Hg (intensive intervention) versus a goal of less than 140 mm Hg (standard intervention) in people without diabetes. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) blood pressure trial tested a similar systolic blood pressure intervention in people with type 2 diabetes. Our study is a secondary analysis of limited access datasets from SPRINT and the ACCORD trial obtained from the National Institutes of Health. In participants without chronic kidney disease at baseline (n=4311 in the ACCORD trial; n=6715 in SPRINT), we related systolic blood pressure interventions (intensive vs standard) to incident chronic kidney disease (defined as >30% decrease in estimated glomerular filtration rate [eGFR] to <60 mL/min per 1·73 m2). These trials are registered with ClinicalTrials.gov, numbers NCT01206062 (SPRINT) and NCT00000620 (ACCORD trial). Findings: The average difference in systolic blood pressure between intensive and standard interventions was 13·9 mm Hg (95% CI 13·4–14·4) in the ACCORD trial and 15·2 mm Hg (14·8–15·6) in SPRINT. At 3 years, the cumulative incidence of chronic kidney disease in the ACCORD trial was 10·0% (95% CI 8·8–11·4) with the intensive intervention and 4·1% (3·3–5·1) with the standard intervention (absolute risk difference 5·9%, 95% CI 4·3–7·5). Corresponding values in SPRINT were 3·5% (95% CI 2·9–4·2) and 1·0% (0·7–1·4; absolute risk difference 2·5%, 95% CI 1·8–3·2). The absolute risk difference was significantly higher in the ACCORD trial than in SPRINT (p=0·0001 for interaction). Interpretation: Intensive lowering of systolic blood pressure increased the risk of incident chronic kidney disease in people with and without type 2 diabetes. However, the absolute risk of incident chronic kidney disease was higher in people with type 2 diabetes. Our findings suggest the need for vigilance in monitoring kidney function during intensive antihypertensive drug treatment, particularly in adults with diabetes. Long-term studies are needed to understand the clinical implications of antihypertensive treatment-related reductions in eGFR. Funding: National Institutes of Health.

AB - Background: Guidelines, including the 2017 American College of Cardiology and American Heart Association blood pressure guideline, recommend tighter control of systolic blood pressure in people with type 2 diabetes. However, it is unclear whether intensive lowering of systolic blood pressure increases the incidence of chronic kidney disease in this population. We aimed to compare the effects of intensive systolic blood pressure control on incident chronic kidney disease in people with and without type 2 diabetes. Methods: The Systolic Blood Pressure Intervention Trial (SPRINT) tested the effects of a systolic blood pressure goal of less than 120 mm Hg (intensive intervention) versus a goal of less than 140 mm Hg (standard intervention) in people without diabetes. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) blood pressure trial tested a similar systolic blood pressure intervention in people with type 2 diabetes. Our study is a secondary analysis of limited access datasets from SPRINT and the ACCORD trial obtained from the National Institutes of Health. In participants without chronic kidney disease at baseline (n=4311 in the ACCORD trial; n=6715 in SPRINT), we related systolic blood pressure interventions (intensive vs standard) to incident chronic kidney disease (defined as >30% decrease in estimated glomerular filtration rate [eGFR] to <60 mL/min per 1·73 m2). These trials are registered with ClinicalTrials.gov, numbers NCT01206062 (SPRINT) and NCT00000620 (ACCORD trial). Findings: The average difference in systolic blood pressure between intensive and standard interventions was 13·9 mm Hg (95% CI 13·4–14·4) in the ACCORD trial and 15·2 mm Hg (14·8–15·6) in SPRINT. At 3 years, the cumulative incidence of chronic kidney disease in the ACCORD trial was 10·0% (95% CI 8·8–11·4) with the intensive intervention and 4·1% (3·3–5·1) with the standard intervention (absolute risk difference 5·9%, 95% CI 4·3–7·5). Corresponding values in SPRINT were 3·5% (95% CI 2·9–4·2) and 1·0% (0·7–1·4; absolute risk difference 2·5%, 95% CI 1·8–3·2). The absolute risk difference was significantly higher in the ACCORD trial than in SPRINT (p=0·0001 for interaction). Interpretation: Intensive lowering of systolic blood pressure increased the risk of incident chronic kidney disease in people with and without type 2 diabetes. However, the absolute risk of incident chronic kidney disease was higher in people with type 2 diabetes. Our findings suggest the need for vigilance in monitoring kidney function during intensive antihypertensive drug treatment, particularly in adults with diabetes. Long-term studies are needed to understand the clinical implications of antihypertensive treatment-related reductions in eGFR. Funding: National Institutes of Health.

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